TMA priority: Enhance enforcement of and accountability under state network adequacy laws and protect Texas’ surprise-billing law.
Session recap: Spurred by physician reports of insurers taking advantage of their leverage in contract negotiations, the Texas Medical Association made network adequacy reform one of its top legislative priorities. After a yearlong effort to strengthen state-level protections, TMA welcomed the unanimous passage of House Bill 3359 in the final days of the regular session, an effort championed by medicine’s allies Rep. Greg Bonnen, MD (R-Friendswood) and Sen. Charles Schwertner, MD (R-Georgetown). Gov. Greg Abbott signed the protections into law in mid-June.
Zachary Jones, MD, an anesthesiologist in Frisco and a member of TMA’s Council on Legislation, called it a major win for medicine in that it codifies the state’s network adequacy rules by putting them into statute and strengthens their enforcement by the Texas Department of Insurance (TDI).
He attributes this success to a coalition effort by TMA, the Texas Society of Anesthesiologists, and other state specialty societies. Although inadequate networks are a “global” problem for physicians, regardless of specialty, he says certain subsets – including anesthesiologists and small practices – are especially vulnerable to out-of-network billing and may lack leverage during contract negotiations.
To this end, HB 3359 restricts insurers from making unilateral contract changes and tackles the problematic waiver process, which Dr. Jones says leaves patients unprotected and in the dark.
Despite Texas’ network adequacy rules being among the strongest in the country, TMA continues to hear from physicians of health plans abusing waivers and offering plans that don’t provide patients with a sufficient panel of in-network physicians.
More than 90% of the commercial health plan networks filed with TDI in 2022 didn’t meet state network adequacy standards and instead operated under a waiver, or “access plan,” detailing how the plan would cover such gaps, according to TDI data.
Tilden Childs, MD, a radiologist in Fort Worth and chair of TMA’s Council on Legislation, says HB 3359 meaningfully reforms this “really out-of-control” process with requirements that health plans regularly monitor network adequacy compliance and guardrails that include new transparency measures and waiver renewal limits.
“In other words, it will encourage the insurance companies to provide adequate networks,” he told Texas Medicine Today.
With this lawmaking victory secured, TMA now looks to the rulemaking process. TDI has indicated it likely will rewrite the state network adequacy rules impacted by HB 3359, which TMA lobbyist Ben Wright says will be a huge undertaking in the interim – and one that TMA will monitor closely.
During the legislative session, TMA also closely watched and fended off bills threatening Texas’ 2019 surprise-billing law, which is intimately tied up with effective network adequacy and differs from the federal surprise-billing law in that it doesn’t favor health plans in arbitrating payment disputes.
For more information, check out TMA’s state advocacy webpage.